Jones, Sally OF
QUEE9�oUp,.y
PINE YIEy4 CEMFTt-RY AND CREMATORIUM
OVKkER ROAD, QVEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745••4477
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Funera Director
S J,- �Gr�cfo�
dame U01 C
Cased. yX3
Oate Of Cremation
Time Cremation Started j
r�15
Time Cremation Completed 3 �.
Type of Container woo
Remarks
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# 5 S3
Town of Queensbury
Pirte View CW*terY and Crematorium
21 Quaker Road,Queensbury, New York, 12844 .
�rery Office: (518)745-4476, Crematorium: (518)745-4477
Auttrorizadon to Cremate
undersigwd requests and autltorims Pkte View Cnematarwm.in accordance Mad and subject
The to ks Rules and Reguwons to
creamte the ream"of: F
Sally Anne Jones
(Name) (Sax)
3.776 Highland Avenue Oneida NY 13421
( ) (CIO (State) (7JP Code)
who died on 10 t h day of
December 20 08
atSracuse NY University Hospital Y
(Ram) (Address)
Name and oddrass of neWS*limp rele M or name of parson autho tzkV aemt WL
David B. Jones 48 Elm St. Hudson Falls, NY
( ) (Address)
Father
Reietlortghip t0 the da009aed
Carleton Funeral Home, Inc.
Name of Funeral Wane
IMPORTANT: the deceased(trss)ar(res no)pacemaker,dekbdikWr,batfary,batWY Pam.Pcwer
t repnae9ertt that to the best of my fatvwtedge,
04 M dWeotive implant or raiftective devbe In his or her body.(Cirde One)
OWWhamhend adtatztlon to arrange for tha c pantatlon of the remains and to dims the dispoeitlon of the
1 rwno that I ooks d power have either been ramoved or may be deshvied•and agree to Pit•d ' n and
aematsd rerrteirts,that arty perrs�ortal poaesesiorts
save harmwa P1ne View Crernetorlum from any and al claims and demands for bss or damages whtdt may be merle e>gttktst them
by of or caxtected wNh dw crerno*m of said remekta as d1rec`ed.whet W sudt daktt8 or dernanrds are or ere not WiW1Y
a
68 Main Street, Hudson Falls, NY
(Address)
Elm Street, Hudson Falls, NY
and Address of Re%Mm or Legal Repreeer** )
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Signed on this date: (�
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f)isposbm of Cremiod Rernakts
I hereby diced Pfne View Crenmwt rm to diapaae of Uta aemated remakrs 99 follows:.
M8ii to
Other arrangennena-Please specify:
ff P*mwetim+of eren sled remains is requested,dteck here XX
Revision:April 18,2007
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